PRESCRIPTION BENEFITS UNDER MEDICAL ASSISTANCE IN
PENNSYLVANIA
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Fee for Service |
Managed Care |
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Many drugs |
Fewer drugs |
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Almost all FDA approved drugs available without prior approval |
Drugs on list must be used unless it is medically necessary to use other drugs on the fee for service list |
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Statewide drug availability |
Each plan has different formulary list |
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List available online |
List available from each plan in varying formats |
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Copayment for some drugs |
No copayment for drugs |
These systems also have different definitions of medical necessity.
Using the wording in this definition is the best approach to obtaining services for patients.
Click here for a definition of medical necessity under
HealthChoices.
Click here for a definition of medical necessity under
Fee-for-Service
FEE FOR SERVICE and MEDICATIONS
All drugs from companies participating in a federal rebate program are eligible to be on the state Medicaid formulary.
Criteria for prior authorization are available from DPW bulletins.
The following five classes of medications may require prior authorization (under some circumstances) under fee for service. Each is followed by a brief summary of prior authorization requirements and the phone number to call for prior authorization.
Each class has different phone numbers to obtain prior authorization. These phone lines are in operation Monday to Friday 8 AM to 4 PM. DPW has plans to allow this to be done online beginning in 2004. Check the OMAP/DPW website for details
Brand Necessary Drugs
http://www.dpw.state.pa.us/omap/provinf/mabull/019415.asp
1-800-558-2660
The prescriber must able to document that the individual patient is in danger of an adverse reaction from the use of the generic equivalent drug and that use of the prescribed brand name drug would eliminate the danger of the adverse reaction.This documentation must be in the patient’s medical file and be able to be provided to DPW on request.
If a prescription is signed "brand necessary" and no prior authorization is on file the pharmacist is unable to dispense any medication. A prior authorization is good for the life of the prescription up to 6 months.
Erectile Dysfunction drugs (Sildenafil or
Viagra®)
http://www.dpw.state.pa.us/omap/provinf/mabull/999908.asp
1-888-379-3668
The patient must be older than 19, and have a diagnosis of erectile dysfunction based on a history and physical examination within the preceding 12 months. Documentation of this must be in the patient’s chart and available to DPW upon request.
Only 4 pills/30 days are covered. The prescription cannot have refills, and each new prescription must be separately prior authorized.
Cox 2 Inhibitors
http://www.dpw.state.pa.us/omap/provinf/mabull/990301.asp
1-888-379-3309
Cox-2 Inhibitors require prior authorization for patients under 70 years of age who are not on anti-coagulants. They also require prior authorization for anyone who is on another anti-inflammatory medication, or for whom the prescribed dosage is above FDA approved limits.
The DPW bulletin provides extensive literature references on the prescribing of Cox-2 inhibitors. The documentation needed to prove medical necessity is
outlined.
H2 blocker anti ulcer drugs for atypical
dosage regimens
http://www.dpw.state.pa.us/omap/provinf/mabull/pdf/019608.pdf
1-800-283-8863
DPW requires prior authorization for anti-ulcer drugs used at acute dosages for more than 90 days, for the use of more than one anti-ulcer drug at a time, or for changes in medication during the initial 90 day prescribing period.
Oxycontin®
http://www.dpw.state.pa.us/omap/provinf/mabull/990110.asp
1-800-558-2660
Oxycontin® must be prior authorized for any
recipient who requires more than two different dosage strengths at
the same time, or more than three tablets/day of any single
strength. It is possible to prescribe up to 6 tablets a day ( 3
tablets each of two strengths) without prior authorization. Detailed
criteria are available online .
No emergency supplies of Oxycontin® are given. Short acting narcotics must be used if the physician is unable to obtain prior authorization at the time of writing the prescription.
HEALTH CHOICES FORMULARIES
Key Information for Physicians regarding Health Choices Formularies
- Each HMO has a different formulary and different
procedures for prior authorization
- All Medicaid HMOs must follow the same state
regulations regarding formulary operations
- Knowledge of these regulations will help you obtain
medically necessary
pharmaceuticals for your patients
The Most Important Rules that help your patients get medically necessary medications:
- The HMO must respond to a request for prior
authorization within 24 hours
- The HMO must allow a pharmacy to dispense a 72 hour
supply of any new medication not on formulary for which there is an immediate
need. If the physician does not complete a prior authorization request the
patient will get only this 3 day supply.
- The HMO must issue a written denial notice within 24
hours of the time that a non-formulary medication prescription is presented to
a pharmacy.
- The HMO must allow a pharmacy to dispense a 15 day
supply of an ongoing medication unless they have previously sent a written
notice of benefit reduction or termination at least 10 days before the old
prescription is due to expire. If the member has filed a grievance or fair
hearing request the HMO must authorize the pharmacy to dispense the medication
until the issue is resolved.
- The HMO must cover the medication if you can demonstrate that it is
medically necessary
If the HMO denies the medication, the patient can appeal to the HMO or to the state, or you can appeal on the patient’s behalf.
You can prior authorize medications using a letter of medical necessity or a form supplied by the plan. These forms are available in provider handbooks, or online from each plan.
Pennsylvania currently has six Medicaid HMOs operating in 3 mandatory service areas. In other areas, there is voluntary participation in one or more of these same HMOs. Some, but not all plans, have formulary information available online.
Click on the plan below to reach their online formulary:
Southeast:
Americhoice
Health Partners
Keystone Mercy
Lehigh Capital:
Amerihealth Mercy
MedPLUS+
Gateway Health Plan – no formulary on line
Southwest:
Gateway Health Plan – no formulary on line
MedPLUS+
UPMC For You - no formulary on line
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